The pelvic floor

Question 1

What are the functions of the pelvic floor?

Answer 1

• Pelvic organ support
• Maintains intra-abdominal pressure during coughing, vomiting, sneezing and laughing
• Facilitates defecation and urination
• Maintains urinary and faecal continence
• Facilitates childbirth
• Sexual function

Question 2

In what ways does the pelvic floor provide support?

Answer 2

1. Suspension
2. Attachment
3. Fusion

Question 3

How does suspension allow the pelvic floor to provide support?

Answer 3

• Maintains pelvic organs in pelvic cavity
• Provides strong sling-like support of inferiorly in pelvis

Question 4

How does attachment allow the pelvic floor to provide support?

Answer 4

• Vagina is supported by attachments to endopelvic fascia, levator ani muscles, and perineal body
• Important in maintaining urinary continence - urethra is compressed by attachments when intra-abdominal pressure is raised

Question 5

How does fusion allow the pelvic floor to provide support?

Answer 5

• Interplay between muscles, fascia and ligaments helps keep pelvic structures in correct place
• Urogenital diaphragm and perineal body fuse

Question 6

Which structures make up the pelvic floor?

Answer 6

• Levator ani muscles
• Urogenital diaphragm/perineal membrane
• Perineal body
• Perineal muscles

Question 7

What are the levator ani muscles?

Answer 7

1. Puborectalis - originates from pubis symphysis
2. Pubococcygeus - originates from pubis symphysis and inserts onto coccyx pubis
3. Iliococcygeus - originates from ischium and inserts onto coccyx pubis

Question 8

What are the deep muscles of the pelvic floor?

Answer 8

• Levator ani muscles
• U-shaped
• Encircle vagina, urethra, and rectum
• Spread in fan shape
• Act like a sling to support pelvic organs

Question 9

What key structure do the levator ani muscles form?

Answer 9

• Perineal body - muscle fibres insert as they encircle vagina/urethra to form this

Question 10

What are the superficial muscles of the pelvic floor?

Answer 10

• Perineal muscles
• Most commonly involved in perineal trauma (accidental, sexual, and obstetric)

Question 11

What are the names of the perineal muscles?

Answer 11

• Bulbospongiosus (encircles labia/base of penis)
• Ischiocavernosus (along line of ischium)
• Superficial transverse perineal muscle

Question 12

What is the function of the perineal muscles?

Answer 12

• Aid in continence

Question 13

What are the ligaments of the pelvis?

Answer 13

• Cardinal ligaments
• Pubocervical ligaments
• Uterosacral ligaments

Question 14

Describe the anatomical location of the cardinal ligaments

Answer 14

• Situated along inferior border of broad ligament of uterus
• Arise from side of cervix and lateral fornix of vagina
• Attach to lateral pelvic wall at level of ischial spine

Question 15

Describe the anatomical location of the pubocervical ligaments

Answer 15

• Attach from cervix to posterior surface of pubic symphysis

Question 16

Describe the anatomical location of the uterosacral ligaments

Answer 16

• Attach cervix to sacrum
• Support uterus

Question 17

What is the urogenital diaphragm?

Answer 17

• Triangular sheet of dense fibrous tissue
• Spans anterior half of pelvic outlet
• Arises from inferior ischiopubic ramus
• Attaches medially to urethra, vagina and perineal body
• Supports pelvic floor

Question 18

What is the perineal body?

Answer 18

• Central position between vagina and rectum
• A number of ligaments and muscles coalesce here
• Levator ani muscles insert here
• Attached posteriorly to external anal sphincter and coccyx
• Support of perineal structures rely on it

Question 19

What is the blood supply to the pelvic floor?

Answer 19

• Internal and external pudendal arteries (drains through corresponding veins)

Question 20

What is the innervation of the pelvic floor?

Answer 20

• Pudendal nerve (S2, S3, S4)

Question 21

What is the lymphatic drainage of the pelvic floor?

Answer 21

• Inguinal lymph nodes

Question 22

What are some common causes of pelvic floor dysfunction?

Answer 22

• Pelvic organ prolapse
• Vaginismus
• Urinary incontinence
• Female Genital Mutilation

Question 23

What is pelvic organ prolapse?

Answer 23

• Refers to loss of support for uterus, bladder, colon or rectum
• Leads collapse of one of these organs into vagina

Question 24

What are the side effects of POP?

Answer 24

• Decrease in quality of life
• Anorectal, urinary, sexual functional disturbances
• Pain
• Infection
• Depressive symptoms

Question 25

How are prolapses classified?

Answer 25

- Anterior - Central - Posterior

Question 26

Describe a prolapse of the anterior compartment

Answer 26

- Cystocoele - bladder prolapses into vaginal space - Urethrocoele - urethral collapse - Cystourethrocoele - bladder and urethra both prolapse

Question 27

What is a central prolapse?

Answer 27

- Uterus collapses down into vaginal space - If entire uterus prolapses = procidentia - Can still occur after hysterectomy = vault prolapse

Question 28

Describe a prolapse of the posterior compartment

Answer 28

- Rectocoele - rectum prolapses into vaginal space - Enterocoele - loops of bowel prolapse into Pouch of Douglas

Question 29

What are the risk factors for prolapse?

Answer 29

- Increased age - Parity - Oestrogen deficiency - Increased abdominal pressure (e.g. due to obesity) - Neurological (spina bifida, muscular dystrophy) - Genetic connective tissue disorder (Marfan's, Ehler Danlos)

Question 30

Outline perineal trauma and obstetric anal sphincter injuries (OASIS)

Answer 30

- Can involve any of the perineal muscles - OASIS involves the anal sphincter complex - 3rd and 4th degree tears - Can result in significant morbidity

Question 31

How can we help prevent tearing while a woman is giving birth?

Answer 31

- Episiotomy - Perineal protection at crowning - Encouraging the mother not to push when the head is crowning

Question 32

What are the symptoms of prolapse?

Answer 32

- History of a dragging sensation or a lump - Feeling of incomplete emptying of the bladder - Double voiding

Question 33

How do we manage pelvic floor prolapse?

Answer 33

- Pessaries provide additional support - Topical oestrogen - Pelvic floor exercises - Hysterectomy, mesh supports

Question 34

What is stress urinary incontinence?

Answer 34

- Urine leaks from bladder during episodes of high intra-abdominal pressure - Occurs if pelvic organs are inadequately supported by pelvic floor

Question 35

What is female genital mutilation?

Answer 35

- All procedures involving partial or total removal of external female genitalia or other injury to female genital organs, whether for cultural or other non-therapeutic reasons

Question 36

What are the types of FGM?

Answer 36

- Type 1 - partial or total removal of clitoris and/or prepuce - Type 2 - partial or total removal of clitoris and labia minora. May or may not excise labia majora. - Type 3 - narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning labia minora/majora with or without excision of clitoris - Type 4 - all other harmful procedures to female genitalia for non-medical purposes

Question 37

What are some of the consequences and complications of FGM?

Answer 37

- haemorrhage, shock, sepsis, blood-borne infections, death - sexual difficulties, fertility issues, chronic pain - increased risk of C-section, post-partum haemorrhage, fear of childbirth - PTSD, flashbacks